Help with understanding c/s surgical report

[Shazer]

I had a c/s 2.5 weeks ago. I just got the surgical report today and am unclear about the meaning and significance of some of the findings.

I tried for a vbac, but after 12 hours of labor, was only at 6 cm. My MW did the first cervical check then and stated that the baby's head was asynclitic. She said we needed to get to a hospital and as she told me later, she thought a repeat section was inevitable given the size or the baby, position of his head, and the degree of pain that I was in . . .

At the hospital, I was found to be 6 cm, 70% effaced with the head "still high." The surgical report from one of two residents who assisted states that the baby was in the left occiput posterior cephalic presentation. "Very thin lower uterine segment" - during the surgery the surgeon made all kinds of comments about how my uterus was going to soon rupture. More from the report: "Right pelvic congestion. Adhesion of the bladder to the uterus." Meconium was found in the amniotic fluid.

After the incision was made, "It was noted at this time that the lower uterine segment was very thin and that there was, on the left side, an even thinner window in the uterus." "It was noted that on the right side that there was pelvic congestion. The lower uterine segment was also noted to be very soft and the tissue seemed friable."

The rest of the report just states the timeline of the procedure from administration of the spinal to when I was taken to recovery.

The surgeon had no bedside manner, so I don't feel comfortable calling his office for an explanation. All of the comments made during the surgery were very negative such as about my stupidity and recklessness in trying for a vbac. What concerns me is that the surgical report seems to indicate that there were some serious problems. The friable comment, the thin uterus, the pelvic congestion, the meconium . . . those comments plus the unbelievable amount of pain I was in lead me to conclude that I wasn't in a good position.

Can anyone shed some light on the surgical report? I just want to be able to wrap my mind around what happened.

[katelove]

Originally Posted by Shazer

I had a c/s 2.5 weeks ago. I just got the surgical report today and am unclear about the meaning and significance of some of the findings.

I tried for a vbac, but after 12 hours of labor, was only at 6 cm. My MW did the first cervical check then and stated that the baby's head was asynclitic. She said we needed to get to a hospital and as she told me later, she thought a repeat section was inevitable given the size or the baby, position of his head, and the degree of pain that I was in . . .

At the hospital, I was found to be 6 cm, 70% effaced with the head "still high." The surgical report from one of two residents who assisted states that the baby was in the left occiput posterior cephalic presentation. "Very thin lower uterine segment" This means that the lower segment of your uterus was unusually thin. This can be an indication that rupture is more likely but it is not an inevitability - during the surgery the surgeon made all kinds of comments about how my uterus was going to soon rupture. More from the report: "Right pelvic congestion. Not sure exactly what he means here. Possibly a comment on some dilated/varicose veins in your pelvis? Adhesion of the bladder to the uterus." This is scar tissue which develops as a result of some type of inflamation. In your case probably the previous c/s. It is very common. In some people it causes enormous problems. In others, no problems at all. It was probably mentioned in this case as it would have needed to be separated duing the the c/s which can increase the risk of damage to your bladder. Meconium was found in the amniotic fluid. Depends whether it was old or fresh, how much etc. May have been a sign of distress but not really enough info to say more.

After the incision was made, "It was noted at this time that the lower uterine segment was very thin and that there was, on the left side, an even thinner window in the uterus." The term "window" is often used to describe tissue which is thin enough to be partially translucent. "It was noted that on the right side that there was pelvic congestion. The lower uterine segment was also noted to be very soft and the tissue seemed friable." Friable tissue means that it was fragile and tore/was damaged easily. Depending on the context friable tisue is usually harder to repair as sutures pull through it/tear it more easily.

What concerns me is that the surgical report seems to indicate that there were some serious problems. The friable comment, the thin uterus, the pelvic congestion, the meconium . . . those comments plus the unbelievable amount of pain I was in lead me to conclude that I wasn't in a good position.

Can anyone shed some light on the surgical report? I just want to be able to wrap my mind around what happened.

Based on the comments you have included here it does sound like your uterus was heading down the path to rupture. *However*, that doesn't mean it *would* have ruptured. It seems to me that you and your midwife made the right decisions given the information you had available - you had unusual pain, the baby was asynclitic which is going to slow descent and increase the pressure on the uterus, you were only 6cm so reasonable to assume that birth was not imminent, especially in view of the asynclitism.

I'm not totally sure what your question is but it sounds like everyone did the right things to me. Apart from the obnoxious comments by the surgeon in OT of course. That is unprofessional and, if you feel up to it, warrants a letter to the hospital IMO.

[soso-lynn]

I would like to point out that a very VBAC unfriendly OB will likely produce a report that sounds a lot scarier than what a different OB would have noted.

[SeattleRain]

It's impossible to know, however, whether or not that was the case or whether or not she really was close to rupturing. I wouldn't jump to conclusions that this doc just didn't want the VBAC, it sounds like the midwife had reservations as well. Not every woman who has a c/s can do a VBAC afterwards, sometimes its just physically impossible with her particular uterus.

[Shazer]

Thank you for the help! I googled everything before posting my thread, but just couldn't find enough info. Given my MW's knowledge and experience, I believe her that a C/S was unavoidable. And I'm glad to have some understanding as to why.

My first c/s, a homebirth transfer, occurred because my mws encouraged pushing as soon as transition ended. I wasn't ready and my cervix swelled. The OB at the hospital didn't want to work with me after going through transition three times at home. This is the c/s I resent because neither the baby or I were in danger. And no complications or issues of concern were listed in that report.

It seems though with the notations of my thin uterus and friable tissue that if we decide to have more children, I most likely will not be able to give birth vaginally. This saddens me but I am glad to know that it isn't just because of ACOG no-vbac policies.

[Bea]

I'd just like to add that since no visual inspection of the uterus of problem free vaginal birthing women is ever observed, it's impossible to say what's normal/common and what's a red flag for problems.

Maybe 90% have thin areas, congestion, 'windows' etc...who actually knows what the average full term uterus looks like?

[AlexisT]

That's not quite true. Many, many sections are done for reasons that have nothing to do with the condition of the uterus, and where it's never been affected by labor: breech, maternal illness, maternal request. Ruptures and dehiscences are extremely rare in unscarred uteri (not that they're widespread in scarred ones--but they are more common). Not to mention the vast number of elective repeat sections, which are done well before labor.

It's certainly possible (and has, in fact, been theorized) that "windows" are more common, and less problematic, in VBAC women than we think--they're sometimes discovered when a repeat CS is performed for other reasons. But they aren't all that common in general, and OBs do enough sections on "normal" women to have a reasonable idea of frequency. It might be a little skewed, but not that much.

I have heard of heavy handed phrasing in surgical reports, but outright lying is rare. Friable tissue is something that would be of concern in any future section--it's not something that he would write just to make sure you never tried VBAC again. "Thin" can be a little bit subjective. They're not using a ruler.

[CherryBomb]

Originally Posted by AlexisT

That's not quite true. Many, many sections are done for reasons that have nothing to do with the condition of the uterus, and where it's never been affected by labor: breech, maternal illness, maternal request. Ruptures and dehiscences are extremely rare in unscarred uteri (not that they're widespread in scarred ones--but they are more common). Not to mention the vast number of elective repeat sections, which are done well before labor.

It's certainly possible (and has, in fact, been theorized) that "windows" are more common, and less problematic, in VBAC women than we think--they're sometimes discovered when a repeat CS is performed for other reasons. But they aren't all that common in general, and OBs do enough sections on "normal" women to have a reasonable idea of frequency. It might be a little skewed, but not that much.

I have heard of heavy handed phrasing in surgical reports, but outright lying is rare. Friable tissue is something that would be of concern in any future section--it's not something that he would write just to make sure you never tried VBAC again. "Thin" can be a little bit subjective. They're not using a ruler.

I'm a vba2c mom, but if this were my report, I would not feel comfortable attempting a vbac. YMMV, of course.